Adolescent Health in India: Still at Crossroads

doi:10.4236/aasoci.2012.24042

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Advances in Applied Sociology

2012. Vol.2, No.4, 320-324

Published Online December 2012 in SciRes (http://www.SciRP.org/journal/aasoci) http://dx.doi.org/10.4236/aasoci.2012.24042

Adolescent Health in India: Still at Crossroads

Mona Gupta1, K. V. Ramani2, Werner Soor s3

1MSG Strategic Consulting, New Delhi, Indi a

2Indian Institute of Management, Ahmedabad, India

3Prince Leopold Institute of Tropica l Medicine, A n twerp, Belgium

Email: mona . hrd @gmail. com; rama ni@ii mahd.ernet.in; [email protected]

Received August 16th, 2012; revised Septembe r 18th, 2012; accepted Septem ber 30th, 2012

Internationally, Adolescent Reproductive and Sexual Health (ARSH) has become a priority programme

approach to help the future generations have a safe, healthy and satisfactory life. India is yet to develop a

comprehensive policy on ARSH mainly due to lack of inter-ministerial collaboration, socio-cultural and

politico-religious factors, even though evidence from surveys and non- governmental organization pro-

jects has corroborated the case for ARSH since late 1980s. Fortunately, recent evidence provided by

Sample Registration Survey (SRS) 1999, Census 2001, National Family Health Survey (NFHS)-II and

District Level Household Survey (DLHS) 2004 particularly on early marriage, teen pregnancy, anaemia

and unmet need for contraception has led GoI to recognize the importance of adolescent health. However,

a comprehensive ARSH policy is yet to emerge, since components of adolescent health are being ad-

dressed by separate ministries and departments. Adolescent health in India is still in an infant stage and at

the risk of infanticide. From “health for the adolescents” to “health with the adolescents”, it is still a long

way to go.

Keywords: Adolescents; Reproductive and Sexual Health; Policy; Qualitative Study; Intersectoral

Coordination; India

Introduction

Adolescents have always remained in a dilemma, as they are

neither considered children nor adults. A similar fate seems to

follow the development of a comprehensive policy on Adoles-

cent Reproductive and Sexual Health (ARSH) in India mainly

due to lack of inter-ministerial collaboration, socio-cultural and

politico-religious factors. India has about 230 million adolescents

in the age group 10 - 19 years, with females comprising about 47%

of the total adolescent population (GoI, 2001). It is this adolescent

population which will enter the workforce in the next 5 - 15 years,

and play a vital role in India’s socio-economic development.

Internationally, ARSH1 has become a priority programme

approach to help the future generations have a safe, healthy and

satisfactory life. In this paper2, we briefly trace the history of

ARSH in India to understand its present situation and deliberate

on problems coming in way of a comprehensive ARSH policy.

It builds upon research undertaken on ARSH in India through-

out the HEPVIC (Health Policy-making in Vietnam, India and

China) project between 2006 and 2009. This research project3

explored the nature of health policy process and more specifi-

cally how the policy processes used evidence, handled the con-

sideration and integration of different policy aspects, and in-

volved a range of different actors4. Three case studies were

selected from each country to understand the policy process in

maternal health. The case studies in India focused on skilled

birth attendance, medical termination of pregnancy (abortion)

and ARSH. Within the wider HEPVIC scope, we report here on

the Indian case study on ARSH and focus on the contribution

(or lack of it) of actors in the policy process5.

4The HEPVIC study conceived policy processes as “the formal and infor-

mal mechanisms through which policies are developed (policy development

and its subsequent implementation (policy implementation)”, and actors as

“individuals or institutions who are associated with, and either involved or

not involved in, policy processes”.

5This study, the main data were collected through in-depth interviews with

key stakeholders. Non-random, purposive sampling and snowballing was

used to select respondents. Separate open-ended questionnaires were de-

veloped for each group of respondents, e.g. government policy-makers and

civil society representatives. During the interview, care was taken to ensure

that respondents were able to speak freely on topics/issues not covered by

the questionnaire but what they thought to be relevant. All interviews were

conducted between March 2007 and October 2008. Out of a total of 34

interviews, 9 were exclusively for the ARSH case study. Politicians though

very impor tant actor cou ld not be int erviewed becaus e of sensitiv ity issues.

All interviews but one were audio recorded with informant’s consent and

transcribed verbatim. One respondent did not permit recording of the inter-

view so extensive notes were taken. Each interview lasted between 45-120

minutes. Secondary data were obtained from literature. NVivo 7.0 was used

as primary aid to organize, index, chart and map the data. After a first round

of interviews, triangulation and analysis, preliminary study results were

resented in a participatory stakeholder workshop (International Workshop

on Maternal Health Policy Process, IIMA, 25-26 October 2007) to allow

feedback from the stakeholders. A second round of interviews and analysis

concluded in the presentation and discussion of the final study results in

another Stakeholder s ’ Wo rkshop (I IMA, 18 Febr uary 2009).

1Internationally, Adolescent Sexual and Reproductive Health (ASRH) is

more widely accep ted ter m. I n a r ig hts -bas ed p ersp ecti ve, “ sex ual heal th ”is

more comprehensive and thus precedes “reproductive health”. In India

however, Adolescent Reproductive and Sexual Health (ARSH) was used

for a long time. Since 2011, GoI has started using the term adolescent

health whic h i n cludes ARSH, school health, mens t ru al hygiene and others.

2This paper briefs on core findings from the study done in India on ARSH

as a part of the HEPVIC (Health Policy-making in Vietnam, India and

China) research project supported by the European CommunitySixth

Framework Programme (INCO-CT- 2005-517746).

3The HEPVIC project involved a consortium of eight partners: University

of Leeds, UK (coordinator); Hanoi School of Public Health, Vietnam;

Indian Institute of Management Ahmedabad (IIMA), India; Fudan Univer-

sity, China; Liverpool School of Tropical Medicine, UK; Prince Leopold

Institute of Tropical Medicine (ITM), Belgium; Royal Tropical Institute,

etherlands; and University of Bologna, Italy. This study was carried out

by IIMA in association with ITM.

M. GUPTA ET AL.

ARSH Policy Process: A Brief History

In India, evidence from surveys and Non Governmental Or-

ganization (NGO) projects has corroborated the case for ARSH

since the late 1980s6. The reports of some of their studies sug-

gest that communities must be involved if gains are to be made

in changing the social norms that discourage youth from ac-

cessing the reproductive and sexual health information they

need (Pande, 2006). Though ARSH at that time had been ac-

cepted in many countries as an important intervention, it started

getting some attention from the Government of India (GoI)

only after the International Conference on Population and De-

velopment (ICPD) in 1994. ICPD emphasized the need to focus

on the reproductive health needs of adolescents as a separate

group (RFSU, 2004).

As a signatory to the ICPD declaration, the Government of

India initiated the development of an ARSH policy. While the

RCH-I (Reproductive and Child Health) Program (1998-2004)

did not make any direct mention of adolescent health needs in

the objectives or beneficiaries, NACP II (National AIDS Con-

trol Program II, 1999-2006) took the challenge seriously and

introduced the School AIDS Education Programme (SAEP) in

the 9th and 11th grades on a voluntary basis throughout India.

Less explicit mention of adolescents was also because RCH-I

was mainly concerned with structures and institutional capaci-

ties that would be utilized in RCH-II (2005-2010), where a

specific focus on adolescent health was planned (UN 2008). As

the overarching National health goals are to attain significant

decline in the TFR, MMR, and IMR, and efforts are on to limit

the HIV spread, reproductive and sexual health became the

entry point of adolescent health also. The RCH-II Program

recognized ARSH as one among the four strategies (besides

Maternal Health, Child Health, and Family Planning) to reduce

MMR, IMR and TFR.

Evidence provided by SRS 1999, Census 2001, NFHS-II and

DLHS-RCH 2004 particularly on early marriage, teen preg-

nancy, anaemia and unmet need for contraception led GoI to

recognize the importance of adolescent health. In India, more

than 50% of the illiterate girls get married before they reach the

legal age of 18 years (ibid). Nearly 27% of married female

adolescents have reported an unmet need for contraception

(MoHFW, 2006). Projections estimated significant increase in

adolescent pregnancies and births. In 2000 there were an esti-

mated 20.2 million adolescent pregnancies which was projected

to increase in subsequent years (Gupta, 2003). According to

National Family Health Survey III (IIPS, 2007), 16% of women

between 15 - 19 years were already mothers or pregnant at the

time of the survey. Adolescent mothers are at a higher risk of

miscarriages, maternal mortality, and morbidity. If a mother is

under the age of 18, her infant's risk of dying in its first year of

life is 60% greater than that of an infant born to a mother older

than 19 (UNICEF, 2008). An inter-country consultation on ado-

lescent health and development (South-East Asia region) or-

ganized by WHO in collaboration with UNFPA and other UN

agencies resulted in setting up Adolescent Friendly Health

Centres (AFHC) by the GoI. The experience of AFHCs dis-

cussed in a subsequent workshop brought out the need to go

beyond clinical services offered by the Health Ministry. In

September 2005, MoHFW organized a national consultation

jointly with WHO and UNFPA on RCH-II ARSH strategy. The

ARSH strategy thus formulated and stated in the National Pro-

gram Implementation Plan (NPIP) of the RCH II (MoHFW,

2005a) program advocates the use of existing public system

infrastructure for ARSH service delivery, working towards

meeting the needs of adolescents, and the need for a delivery

strategy looking at different stages of development, needs and

problems of adolescents. The RCH-II ARSH strategy was

communicated to the states in May 2006 in a Dissemination

workshop. However a review of the state RCH plans and ex-

penditure for the year 2008-09 shows that most of the states are

yet to implement ARSH in all its districts. Fourteen of the 35

states and UTs had reported nil expenditure for ARSH in

2008-09 (MoHFW, 2009).

Multiple Actors, No Ownership

In India, components of adolescent health are being looked

after by separate ministries and departments. The Ministry of

Health and Family Welfare (MoHFW) focuses on delivering

adolescent health services. The Adolescent Education Pro-

gramme (AEP) and sex education come under the Department

of Education in the Ministry of Human Resource Development

(MoHRD), while its earlier version SAEP was administered by

National AIDS Control Organization. The program on nutrition

and counselling of adolescent girls—Kishori Shakti Yojana—is

being looked after by the Ministry of Women and Child De-

velopment (MoWCD) under its Integrated Child Development

Scheme (ICDS). The National Youth Policy 2003, of the Min-

istry of Youth Affairs and Sports (MoYaS) recognises adoles-

cents (15 - 19 years) as distinct from the youth (20 - 35 years

age), but its focus on ARSH is limited to advocacy on ARSH

and life skills (MoYaS, 2008). Thus each ministry is looking

after one component of adolescent health and therefore a com-

prehensive ARSH policy is yet t o emerge.

As a respondent from a national NGO commented:

Every department has its own concern; nobody is concerned

about the adolescents as a vulnerable group. MoYaS’s target

population is youth. Its goals are nationalism, sports and per-

sonality development. WCD is more concerned with nutrition

and empowerment of women. Ministry of Health is into service

delivery. Along with other health concerns Adolescent Repro-

ductive and Sexual Health also features in its long list.

Commenting on its multi-sectoral characteristic and the role

of the health sector, a respondent from an UN organization

said:

There are domains in ARSH, which can be attended to by so

many actors. In addition to the civil society, education depart-

ment, youth department, social justice department, women and

child etcetera need to pitch in. Health sector has limited capac-

ity and efficiency especially in developing world. We have to

define the health sector’s role in the multi-sectoral framework.

While collaborating we should be clear that this is what the

health sector can do.

Though collaboration and coordination is essential for ARSH,

the process of implementation of the Indian ARSH strategy has

not addressed the inter-ministerial coordination satisfactorily.

The National Programme Implementation Plan (NPIP) of RCH

II says that “Department of Health and Family Welfare will

need to steer policy dialogue and partnerships with other de-

partments for inter-sectoral activities” (MoHFW, 2005b). But

6Organisations like Parivar Seva Sanstha, the International Centre for Re-

search on Women (ICRW) Ind i a o f fi ce, Swaasthaya, t h e H ealth Inst i tu t e f o r

Mother and Child (MAMTA) and Family Health International India started

adolescent health projects and provided programmatic evidence, where as

Census of India, the three rounds of the National Family Health Survey

(NFHS) and the 2006-2007 Youth Surveys provided additional quantitative

evidence.

M. GUPTA ET AL.

the 11th five-year plan document mentions MoYaS as the nodal

ministry for youth and adolescent, though with some reserve-

tions: “The MoYaS is the nodal ministry for development and

empowerment of youth and adolescents in the country. MoYaS’

role and responsibilities in this context are still not clearly de-

fined, which affects its schemes and programmes in terms of

their monitorable deliverables and outcomes on the one hand,

and dovetailing them in an integrated framework with programs

of other ministries” (Planning Commission, 2007). Among the

stakeholders interviewed for this research there is consensus

that MoYaS lacks the power to fulfil this nodal role. The

MoYaS is not a member in the Mission Steering Group and the

Empowered Programme Committee—the highest policy mak-

ing and steering institution under the National Rural Health

Mission (NRHM), which includes ministries such as Health and

Family Welfare, Rural Development, Panchayati Raj and Hu-

man Resources Development (GoI , 2005).

Highlighting NRHM as an opportunity to initiate inter-sec-

toral collaboration in ARSH a senior government officer re-

marked: “As NRHM is the umbrella programme for all health

issues and stresses on inter-sectoral collaboration to achieve its

objectives, it may be useful to view ARSH policy development

as an important inter-sectoral activity under NRHM.”

But in the third year of NRHM (2008-09), ARSH accounted

for only 0.4% (less than 1%) of the total expenditure under

RCH/NRHM7.

Multi-sectoral nature of adolescent health becomes even

more complicated because of the non-homogeneity of adoles-

cents as a group. Adolescents could be boys and girls, married

and unmarried, with diverse sexual preferences, in-school and

out of school, working and unemployed, migrants and those at

home, of various castes, cultures, religions and economic strata.

Programmes and schemes of most ministries and departments

cater to some, but leave out too many.

The parliamentary committee looking into what has been

termed the “sex education controversy” has expressed dissatis-

faction on the total lack of coordination amongst various agen-

cies in formulating and implementing the Adolescent Education

Programme (AEP). The Committee would like the Ministry of

HRD to oversee the process of revision of AEP under its super-

vision, direction and control (ibid). The AEP reaches only the

school children, and not the large segment of out-of-school

boys and girls8. In Gujarat, Mamta-Taruni addresses out-of-

school girls, but leaves out the out-of-school boys. MoYaS

caters to rural youth through its Nehru Yuva Kendras, but its

focus is more on nationalism and sports and not on ARSH.

Many NGOs are trying to cater to the adolescents, but their

reach is limited in scope and coverage.

The policies at both federal and state levels either belong to

specific sectors like health, education, population, nutrition,

HIV/AIDS etc. or the policies address specific population seg-

ments like youth, women, and children, and therefore the em-

phasis on adolescents gets diluted (MAMTA, 2001).

The Context Trap

Complexity of socio-cultural and politico-religious factors

adds on to the complicated interplay of actors. To start with, the

concept of “adolescent” has not been a common one in India,

where traditionally childhood has been seen as leading directly

to adult life. As one of the respondents voiced, “Problem is

more serious for people who are illiterate and their children

who do not go to school. When the children turn 13 or 14 years

their parents think that they are into adulthood, and they should

work. By 18 they must get married”.

An INGO respondent synthesized: “A child suddenly be-

comes adult after marriage”.

Government services delivery fails to recognize the transition

through adolescence, particularly in the case of married teenag-

ers. As an INGO respondent commented “A married adolescent

for a provider is quite like an adult, in the adult role. Whether

the communication capacity of the client has evolved or not,

whether the decision-making capacity of the adolescent client is

of adult level or not, the provider is not aware”.

Socially, married girls are most vulnerable. Within a patriar-

chal family structure, women have relatively little power, but

young and newly married women are particularly powerless,

secluded, and voiceless. As one of the respondents from an

INGO who has worked extensively in the field of adolescent

health said:

They (married girls) are more at risk. They are less likely to

be allowed out of house and so less likely to access services.

They have very little decision-making power. They probably

don’t have much communication with their husbands, nor does

any health care provider even worry about them until they have

a child. An adolescent married girl is socially isolated and has

very little contact with her parental home.

As argued by several of our respondents, there is tremendous

societal pressure on girls for marrying early and having a child

early. In fact, there are strong pressures on women to prove

their fertility as soon as possible after marriage: social accep-

tance and economic security in the marital home are established

largely through fertility, and particularly through the birth of a

son (Jejeebhoy, 1998). Adolescent girls have little choice about

whom and when to marry, whether or not to have sexual rela-

tions, and when to bear children. A proposal that was intro-

duced to reduce the legal age at marriage for boys from 21

years to 18 years probably would have put still more pressure

on girls, but has been rejected (UNI, 2009).

In India, the politico-religious context has played a very sig-

nificant role in determining policy and the content of education

to be provided to the youth. While parents articulate a need to

provide reproductive and sexual health education to their chil-

dren, political and religious leaders have tended to decide what

is good for the youth. Those who apparently have the least say

are the key stakeholders: the adolescents themselves. Adoles-

cents have found it difficult to voice their needs. When it comes

to reproductive and sexual needs it becomes all the more diffi-

cult: sex is a taboo subject. Even the subdued adolescents’ de-

mand seems to be only marginally taken into account in the

policy process. As stated by a policy-maker the government

does not pay much attention to the adolescents’ perspective in

formulating ARSH policy:

The formal approval of any government policy (central or

state government) requires that the policy draft document is

tabled in the parliament (or the state legislature) for debate and

discussion, or taken to the cabinet for its approval when the

parliament (or the state legislature) is not in session. It is up to

the parliamentarians (legislators) to get inputs from their con-

7With increased focus the expenditure on Adolescent health has increased

to 2.5% in 2011-12 of the total expenditure under RCH/NRH M.

8School dropout rates for girls are 19% and 66% in the age groups 11 - 14

years and 1 5 - 19 year s resp ectively ( IIPS, 1999). Th e corresp onding statis-

tics for boys are 20% and 51% respectively. In addition to school dropouts,

an average of 22% of girls and 7% of boys in the age group 15 - 19 years

never atte n ded school.

322

M. GUPTA ET AL.

stituencies and stakeholders for discussions during the delibera-

tions of the policy. Yet, an average youth doesn’t even know

what the whole youth policy is about. Efforts are made in

workshops and seminars to give the adolescents and youth a

platform to raise their voice. But such efforts are very few.

At times, lack of attention comes close to plain negation:

“Because of the potential political backlash and the whole cul-

tural milieu, I think nobody wants to have any major impetus

on it. ‘Our youth don’t have sex’—this attitude still exists”:

said a respondent from an INGO working with adolescents. Yet,

population-level data (Population Council and IIPS, 2007) re-

veal that premarital sex among female and male youth is a real-

ity. At the same time, a very marginal percentage of the respon-

dents in the IIPS study is engaged in discussions on sexual and

reproductive systems, including pregnancy, with their parents.

Lack of health awareness among adolescents is another is-

sue9 which is more widely recognised. One of the government

policy-makers, quoting an opinion poll conducted by one of the

leading fortnightly magazine, indicated that “There is an utter

lack of awareness and knowledge about sex and sexuality, ways

to use contraceptive methods among the youth”.

But lack of knowledge does not equal lack of demand. As

one NGO respondent indicated:

Parents of adolescents would like their children—both boys

and girls—to receive reproductive health and sex education.

Even the adolescents and youth themselves have voiced their

needs for sex education. Further, the youth want to know and

learn about sex education from a formal source such as school,

or college and taught by a teacher or a health provider. Parents

do not feel comfortable talking about sex to their children and

therefore prefer that their children receive such information

from schools from their teachers.

In spite of the fact that both adolescents and their parents

have expressed a need for sex education, and government offi-

cials recognizing that adolescents lack awareness about sex and

sexuality, efforts to provide sex education through the SAEP

came under attack (some termed it as cultural hijack) and were

discontinued in several states because of political pressure. A

political leader had argued that the attempt to impart sex educa-

tion is a ploy of the multinational companies that are keen on

promoting the sale of condoms and other sex devices. Some

religious leaders even argued that “sex education would make

adolescents promiscuous”. In a country where Valentine’s Day

celebrations and vibrating condoms are viewed as capable of

unsettling the nation, there is no novelty in these arguments.

One is only too familiar with them. But their efficacy in stalling

sex education in schools is a matter for worry (Anandhi, 2007).

The report from the Rajya Sabha committee on petitions

(Rajya Sabha, 2009) officializes the plea for scaling down sex

education. The committee appears satisfied with the revision of

the AEP by a commission led by the chairman of the Central

Board of Secondary Education. But it also advises that chapters

like “Physical and Mental Development in Adolescents” and

“HIV/AIDS and other Sexually Transmitted Diseases” should

be removed from the present curriculum and included in the

books of biology, not before the 10 + 2 stage.

Conclusion

Adolescent health in India is still in an infant stage, and at

risk of infanticide. If we want to deliver a comprehensive ser-

vices package to our adolescents, then we have first to over-

come a range of obstacles: traditional society, cultural restrict-

tions—especially for girls—and the political-religious context.

Only government action can put these hindrances aside.

But government actors are far from steering in the same di-

rection. Improved coordination should be a first step. Coordina-

tion of policy processes amongst different departments and

different ministries—especially the need to identify a lead

agency which has the mandate and power to coordinate—is the

key to any government policy. In ARSH, shattered by many

and buried in complexity, coordination and steering becomes

imperative. However, this can only be a first step. From ‘health

for the adolescents’ to ‘health with the adolescents’, there is

still a long way to go.

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324